food stamps 28 feb 2014

**Keep in mind that you do not need to mail this print-out to your local agency.**

Thank you for using COMPASS to apply for benefits!

MICHAEL MINYARD, your application has been submitted to Online Services on February 28, 2014 at 01:54 P.M.

If you have questions regarding your online application please contact Online Services at 1-877-423-4746.

Your application tracking number is 4096151343.

Be sure to write this number down or print this page for your records.

In your application, you have asked for these benefits: Food StampsFamily MedicaidChild Care

As a next step, your worker may ask for proof of some of the things you told us in your application. This checklist will helpyou gather these items. If you can't find something, your worker may be able to help you get the proof you need.

Keep in mind that this list is based only on what you told us today. There may be other items that your worker will ask youto provide.

Proof of IdentityProof of who you are, like a driver's license, ID card.

Proof of ResidenceCurrent Georgia issued Driver License/ID Card, current lease, current mortgage statement, statement from landlord orperson with whom you reside, utility bill (gas, electric, telephone).

Social Security NumberSocial Security numbers for everyone you want to receive benefits. Immigrants may potentially be eligible for benefitswithout a social security number.

Proof of Citizenship or Immigration Status (Only for those seeking benefits)Proof of citizenship such as a birth certificate, U.S. passport, hospital record. Proof of immigration status such as residentimmigration card, passport, visa, I-94, I-181, or other Department of Homeland Security (DHS) documentation.Any adult other than the head of household must fill out and sign a form 216.Additional examples of Proof of Citizenship for Medicaid applicants can be found in Form 218.

Proof of Job Income

COMPASS Apply For Benefits Page 1 www.compass.ga.gov

For everyone who has a job or has had a job in the last three months, you will need to prove how much money they earnat each job they have. You can give your case worker pay stubs from employer(s) by providing at least one month or 4weeks of pay for each week paid in the month.

Proof of Medical CostsHere are some examples of what you can give your worker to prove your medical costs: copies of billing statements,itemized receipts, or statements from your pharmacy.

Proof of School EnrollmentHere are some examples of what you can give your case worker to prove school enrollment: School Registration, ClassSchedule, Report Card, Letter from Registrar's Office, Payment Receipt.

Proof of ResourcesHere are some examples of what you can give your case worker to prove your resources: bank statements, propertydeeds, vehicle registration, copy of life insurance policies, burial contracts.


Application Summary Here is a summary of what you told us, as well as important information about your rights and responsibilities.

Case Summary

Basic Information

Case SummaryFirst NameMiddle InitialLast Name

Relationshipto Applicant

Is thispersonapplying forbenefits

Date ofBirth

SocialSecurityNumber

Gender Race/Ethnicity U.S. Citizen,QualifiedAlien/ImmigrantorHmong/Highland Laotian

Pregnant(Y/N)

Lives inthe homewithApplicant

Employed(Y/N)

MICHAEL HMINYARDAge: 57

Applicant FSMACC

08/17/1956 255-98-2137 Male White US Citizen N Y

stephani pMINYARDAge: 39

is the wife of FSMACC

10/09/1974 260-29-9756 Female White US Citizen N Y N

ian b MINYARDAge: 7

is the son of FSMACC

07/28/2006 673-30-6964 Male White US Citizen N Y N

matthew mMINYARDAge: 11

is the son of FSMACC

09/13/2002 672-16-5250 Male White US Citizen N Y N

Your Name Date of Birth Gender CountyMICHAEL H MINYARD 08/17/1956 Male ChathamReceived Food Stamps this month in GA or anotherstate?

Yes

Visually Impaired? NoHearing Impaired? NoInterpreter needed for interview? NoDo you and/or the applicant need assistance whencommunicating with us? If so, check all that apply?Primary Language EnglishIf you are not registered to vote where you live now,would you like to apply to registerto vote here today?

No

Is anyone in your home amigrant or seasonal farmworker?

If yes, did his or her jobended recently?

If yes, will he or she get more than $25 from a new jobor other source in the next 10 days?

NoReason Child Care isneeded

Has this person received subsidized child care (CAPS)in Georgia before?

If yes, what county did thisperson live in when theyreceived CAPS?

Working No N/AWhere You Live Mailing Address1244 CRAWFORD WAY POOLER, GA 31322


People In Your Home

Has the household lived at any other addresses in thepast 5 years?

No

Contact InformationPrimary Phone (912) 224-2345Alternative Phone (912) 988-8040Work PhoneEmail Address [email protected] way to get in touch with you Primary PhonePhone Type (if Deaf or Hard of Hearing) NoneBest time to get in touch with you Lunch Hour


PersonMICHAEL H MINYARDAge: 57

Date of Birth Gender Marital Status08/17/1956 Male Married but Living ApartPreviously ReceivedBenefits?

Programs Requested

Yes Food StampsFamily MedicaidChild Care

Is this person known byany other name?

Alternative Name

NoSSN SSN Application Date US Citizen?255-98-2137 US CitizenDoes this person live atsame address as you?

Address

When did this personcome to the U.S. to live?

When did this person get qualified, legal status in theU.S.?

Does this person have asponsor?

What country is this person from?

If this person has animmigrant registrationnumber, what is it?

Type of refugee If other, please specify

Declaration of Citizenship

If I am applying for health coverage for myself, I certify under penalty of perjury that Iam a U.S. Citizen and/or lawfully present in the United States. If I am a parent or legalguardian, I certify that the applicant(s) is a U.S. Citizen and/or lawfully present in theUnited States.Resident of GA? Where does he/she live?Yes In This HomeEthnicity and RaceIs this person Hispanic? No

White


Personstephani p MINYARDAge: 39

Date of Birth Gender Marital Status10/09/1974 Female MarriedPreviously ReceivedBenefits?

Programs Requested



Alternative Name


Address

YesWhen did this personcome to the U.S. to live?







Resident of GA? Where does he/she live?Yes In This HomeEthnicity and RaceIs this person Hispanic? No

White


Personian b MINYARDAge: 7

Date of Birth Gender Marital Status07/28/2006 Male Never MarriedPreviously ReceivedBenefits?

Programs Requested



Alternative Name


Address








Resident of GA? Where does he/she live?Yes In This HomeEthnicity and RaceIs this person Hispanic? No

White


Relationship Information

Personmatthew m MINYARDAge: 11

Date of Birth Gender Marital Status09/13/2002 Male Never MarriedPreviously ReceivedBenefits?

Programs Requested



Alternative Name

SSN SSN Application Date US Citizen?672-16-5250 US CitizenDoes this person live atsame address as you?

Address








Resident of GA? Where does he/she live?In This Home

Ethnicity and RaceIs this person Hispanic? No

White

Person

MICHAELAge: 57

Relationships Do they buy food and eat mealstogether?

is the husband of stephani Yesis the father of ian Yesis the father of matthew Yes

Person

stephaniAge: 39


is the mother of ian Yesis the mother of matthew Yes


Your Dependents

Claimed Dependent on Someone Else's Tax Return

Questions About the People In Your Home

Person

ianAge: 7


is the brother of matthew Yes

Who DependentsMICHAELAge: 57

ian

MICHAELAge: 57

matthew

Who Claimed ByianAge: 7

MICHAEL

matthewAge: 11

MICHAEL

Person Disability

Blindness

SpecialNeeds

FosterChildrenInformation

ChildProtectiveServices

DivisionofFamilyandChildrenServicesCustody

TANF

GrandparentCaringforGrandchild

DrugFelonies

SanctionedbyFSET

FoodStampDisqualification

AvoidingProsecution

ViolatingParole

OutofStateBenefits

Convicted ofFalseInformation

VoluntarilyQuitJob

Convicted ofTradingFoodStampsforDrugs

Convicted ofBuyingorSellingFoodStamps

Convicted ofTradingFoodStampsforGuns

MICHAELAge: 57

No No N/A N/A N/A N/A No No No No No No No No No No No

No No stephaniAge: 39

No No N/A N/A N/A N/A No No No No No No No No No No

No No No ianAge: 7

No No No No No No No N/A N/A N/A No N/A N/A No No


Other Benefits

Medicare Part A or Part B

You told us that no one in your home has this kind of income, benefit, or bill.

Health Insurance Policy Information


Health Insurance Policy Information


Nursing Home Details


Hospice Details


Hospital Stay Details


No No No No matthewAge: 11

No No No No No No No N/A N/A N/A No N/A N/A No

Person Hospital Stay Currently in FosterCare

Previously in FosterCare for Six Months

MICHAELAge: 57

No No No

stephaniAge: 39

No No No

ianAge: 7

No No No

matthewAge: 11

No No No


Liquid Asset Information

Vehicle Asset Information

Real Estate Asset Information

Burial Asset Information


Life Insurance Information


Other Property Asset Information


Job Income Information

PersonMICHAELAge: 57

Type Value Account Number Bank Name Other OwnersCash $50Type Value Account Number Bank Name Other OwnersChecking Account $50 1294636 the coastal bank


Type Year Make Model Amount Owed Other OwnersCar 2009 toyot yaris $10000


Type Is this aprimaryResidence?

Value CurrentlyTrying to sellthis property?

Address Other Owners

House Yes $90000 1244 crawfordwayPOOLER GA31322


Self Employment Information


Other Income Questions

Other Income Information


Housing Bills Questions

Room and Meals


Name of Employer Address of Employeraerotek staffing 7077 Bonneval Road

jacksonville FL 32216(904) 527-5600

Job Start Date Job End Date Date of First Paycheck01/06/2014 01/17/2014Is currently onstrike

Last paycheck date Final Paycheck Amount

Pay Period Amount Average Hours Hourly rate of payWeekly $672 32 21Additional Comments About Your Job Is this job part of a federal or state

funded work-study program?Only 8 dollars is taxable. this is called perdiem.

No

Person Getting income from providing room and/or board?MICHAELAge: 57

No

stephaniAge: 39

No

ianAge: 7

N/A

matthewAge: 11

N/A

Does your household get housing or rent assistance? NoIf your household gets Public Housing Assistance, are you charged with a utilityexpense?

No


Housing Bills Information

Utility Bills Questions

Utility Bills Information

Other Bills Questions

Dependent Care Bills


Person Paying for room and meals?MICHAELAge: 57

No

stephaniAge: 39

No

ianAge: 7

N/A

matthewAge: 11

N/A

Homeowner's Insurance $50.00Mortgage $537.00Property Tax $50.00

What is your household's primary heating or cooling source? ElectricHas your household received help from Low Income Energy Assistance Program(LIHEAP) at your current address, during the past 12 months?

No

ElectricityPhone or Cell Phone ServiceWaterNatural GasTrash RemovalSewer


Type of Medical Bill AmountDoctor $97.00Dental $100.00Hospital Bills $20.00Prescription Costs $570.00


Child Support Details


Other Expenses

School Enrollment Information

Person Unpaid Medical BillsMICHAELAge: 57

Yes

stephaniAge: 39

No

ianAge: 7

No

matthewAge: 11

No

Person

MICHAELAge: 57

Graduation Status EnrollmentStatus

ImmunizationCurrent?

Next Shot Date

Earned Bachelors Degree Not in schoolType Of School School Name School Address Date of

Graduation

Caring for achild under 6years old?

Caring for achild 6 to 12years old anddaycare notavailable?

Caring for achild 6 to 12years old andenrolled indaycare?

None of theabove

In a federal orstate fundedwork-studyprogram?

No No No No No

Person

stephaniAge: 39



Next Shot Date

Earned high school equivalency orgeneral equivalency diploma (GED)

Not in school

Type Of School School Name School Address Date ofGraduation




None of theabove


No No No No No


Person

ianAge: 7



Next Shot Date

Second Grade Full time Yes 01/01/2015Type Of School School Name School Address Date of

GraduationElementary School pooler elem

poolerGA 31322(912) 395-3625




None of theabove


No No No No No

Person

matthewAge: 11



Next Shot Date

Fifth Grade Full time Yes 01/01/2015Type Of School School Name School Address Date of

GraduationElementary School pooler elem

poolerGA 31322(912) 395-3625




None of theabove


No No No No No


HIPAA Notice of Privacy Practices Georgia Department of Human Services

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED ANDDISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

If you have any questions about this notice, please contact: Georgia Department of Human Services HIPAA Privacy Officer [email protected] (404) 657-9761 phone (404) 657-1123 fax

The Department of Human Services (DHS) is an agency of the Executive Branch of Georgiagovernment charged with the administration of numerous federal programs responsible for thestorage, use and maintenance of medical and other confidential information. Federal and state lawsestablish strict requirements for these programs regarding the use and disclosure of confidential andprotected information. DHS is required to comply with those laws as noted throughout this Notice.OBLIGATIONS OF THE DEPARTMENT OF HUMAN SERVICES:DHS is required by law to:

Maintain the privacy of protected health information; Give you this notice of our legal duties and privacy practices regarding health information aboutyou; and Follow the terms of our notice currently in effect.

HOW DHS MAY USE AND DISCLOSE HEALTH INFORMATION:The following describes the ways DHS may use and disclose health information that identifies you("Health Information"). Except for the purposes described below, DHS will use and disclose HealthInformation only with your written permission. You may revoke such permission at any time by writingto the HIPAA Privacy Officer at the contact information above.For Treatment. DHS may use and disclose Health Information for your treatment and to provide youwith treatment-related health care services. For example, DHS may disclose Health Information todoctors, nurses, technicians, or other personnel who are involved in your medical care and need theinformation to provide you with medical care.

For Payment. DHS may use and disclose Health Information so that DHS or others may bill andreceive payment related to your care, an insurance company, or a third party for the treatment andservices you received. For example, DHS may provide your health plan information so that treatmentmay be paid for.COMPASS Apply For Benefits Page 16 www.compass.ga.gov

For Health Care Operations. DHS may use and disclose Health Information for health careoperations purposes. These uses and disclosures are necessary to make sure that quality care isreceived and to operate, manage,and administer the functions of the agency. For example, DHS mayuse and disclose information to make sure the medical care you receive is of the highest quality.DHS also may share information with other entities that have a relationship with you (for example,your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services.DHS may use and disclose Health Information to contact you to remind you of an appointment with aphysician. DHS also may use and disclose Health Information to tell you about treatment alternativesor health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, DHS may shareHealth Information with a person who is involved in your medical care or payment for your care, suchas your family or a close friend. DHS also may notify your family about your location or generalcondition or disclose such information to an entity assisting in a disaster relief effort.

Research. Under certain circumstances, DHS may use and disclose Health Information for research.For example, a research project may involve comparing the health of patients who received onetreatment to those who received another, for the same condition. Before DHS uses or disclosesHealth Information for research, the project will go through a special approval process. Even withoutspecial approval, DHS may permit researchers to look at records to help them identify patients whomay be included in their research project or for other similar purposes, as long as they do not removeor take a copy of any Health Information.

SPECIAL SITUATIONS:

As Required by Law. DHS will disclose Health Information when required to do so by international,federal, state or local law.

To Avert a Serious Threat to Health or Safety. DHS may use and disclose Health Informationwhen necessary to prevent a serious threat to your health and safety or the health and safety of thepublic or another person.Disclosures, however, will be made only to someone who may be able tohelp prevent the threat.


Business Associates. DHS may disclose Health Information to our business associates thatperform functions on our behalf or provide us with services if the information is necessary for suchfunctions or services. For example, DHS may utilize the services of a separate entity to performbilling services. All DHS business associates are obligated to protect the privacy of your informationand are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, DHS may use or release HealthInformation to organizations that handle organ procurement or other entities engaged in procurement,banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation andtransplantation.

Military and Veterans. If you are a member of the armed forces, DHS may release HealthInformation as required by military command authorities. DHS also may release Health Information tothe appropriate foreign military authority if you are a member of a foreign military.

Workers Compensation. DHS may release Health Information for workers compensation or similarprograms. These programs provide benefits for work-related injuries or illness.

Public Health Risks. DHS may disclose Health Information for public health activities. Theseactivities generally include disclosures to prevent or control disease, injury or disability; report birthsand deaths; report child abuse or neglect; report reactions to medications or problems with products;notify people of recalls of products they may be using; a person who may have been exposed to adisease or may be at risk for contracting or spreading a disease or condition; and the appropriategovernment authority if it is believed a patient has been the victim of abuse, neglect or domesticviolence. DHS will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities. DHS may disclose Health Information to a health oversight agency foractivities authorized by law. These oversight activities include, for example, audits, investigations,inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. DHS may use or disclose your Protected Health Information toprovide legally required notices of unauthorized access to or disclosure of your health information.


Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, DHS may disclose HealthInformation in response to a court or administrative order. DHS also may disclose Health Informationin response to a subpoena, discovery request, or other lawful process by someone else involved inthe dispute, but only if efforts have been made to tell you about the request or to obtain an orderprotecting the information requested.

Law Enforcement. DHS may release Health Information if asked by a law enforcement official if theinformation is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2)limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3)about the victim of a crime even if, under certain very limited circumstances, we are unable to obtainthe persons agreement; (4) about a death we believe may be the result of criminal conduct; (5) aboutcriminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crimeor victims, or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors. DHS may release Health Information to acoroner or medical examiner. This may be necessary, for example, to identify a deceased person ordetermine the cause of death. DHS also may release Health Information to funeral directors asnecessary for their duties.

National Security and Intelligence Activities. DHS may release Health Information to authorizedfederal officials for intelligence, counter-intelligence, and other national security activities authorizedby law.

Protective Services for the President and Others. DHS may disclose Health Information toauthorized federal officials so they may provide protection to the President, other authorized personsor foreign heads of state or to conduct special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under thecustody of a law enforcement official, DHS may release Health Information to the correctionalinstitution or law enforcement official. This release would be if necessary: (1) for the institution toprovide you with health care; (2) to protect your health and safety or the health and safety of others;or (3) the safety and security of the correctional institution.

USES AND DISCLOSURES THAT REQUIRE DHS TO PROVIDE YOU AN OPPORTUNITY TOOBJECT AND OPT


Individuals Involved in Your Care or Payment for Your Care. Unless you object, DHS maydisclose to a member of your family, a relative, a close friend or any other person you identify, yourProtected Health Information that directly relates to that person.s involvement in your health care. Ifyou are unable to agree or object to such a disclosure, DHS may disclose such information asnecessary if it is determined that it is in your best interest based on the professional judgment ofDHS.

Disaster Relief. DHS may disclose your Protected Health Information to disaster relief organizationsthat seek your Protected Health Information to coordinate your care, or notify family and friends ofyour location or condition in a disaster. DHS will provide you with an opportunity to agree or object tosuch a disclosure whenever it is practical to do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

The following uses and disclosures of your Protected Health Information will be made only with yourwritten authorization:1. Uses and disclosures of Protected Health Information for marketing purposes; and2. Disclosures that constitute a sale of your Protected Health InformationOther uses and disclosures of Protected Health Information not covered by this Notice or the lawsthat apply to DHS will be made only with your written authorization. If you do provide DHS anauthorization, you may revoke it at any time by submitting a written revocation to the above-referenced Privacy Officer. Upon receipt, DHS will no longer disclose Protected Health Informationunder the authorization. However, disclosures made in reliance upon your authorization before yourevoked it will not be affected by the revocation.

YOUR RIGHTS:

You have the following rights regarding Health Information DHS has about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may beused to make decisions about your care or payment for your care. This includes medical and billingrecords, other than psychotherapy notes. To inspect and copy this Health Information, you mustmake your request, in writing, to the above referenced HIPAA Privacy Officer. DHS has up to 30days to make your Protected Health Information available to you and DHS may charge you areasonable fee for the costs of copying, mailing or other supplies associated with your request. DHSmay not charge you a fee if you need the information for a claim for benefits under the Social Security


Act or any other state of federal needs-based benefit program. DHS may deny your request incertain limited circumstances. If DHS does deny your request, you have the right to have the denialreviewed by a licensed healthcare professional who was not directly involved in the denial of yourrequest, and DHS will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Informationis maintained in an electronic format (known as an electronic medical record or an electronic healthrecord), you have the right to request that an electronic copy of your record be given to you ortransmitted to another individual or entity. DHS will make every effort to provide access to yourProtected Health Information in the form or format you request, if it is readily producible in such formor format. If the Protected Health Information is not readily producible in the form or format yourequest, your record will be provided in either our standard electronic format. If you do not want thisform or format, a readable hard copy form will be provided. DHS may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of yourunsecured Protected Health Information.

Right to Amend. If you feel that Health Information DHS has is incorrect or incomplete, you mayrequest DHS to amend the information. You have the right to request an amendment for as long asthe information is kept by or for our office. To request an amendment, you must make your request,in writing, to the above-referenced HIPAA Privacy Officer.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosuresDHS made of Health Information for purposes other than treatment, payment and health careoperations or for which you provided written authorization. To request an accounting of disclosures,you must make your request, in writing, to the above-referenced HIPAA Privacy Officer.

Right to Request Restrictions. You have the right to request a restriction or limitation on the HealthInformation DHS uses or disclosed for treatment, payment, or health care operations. You also havethe right to request a limit on the Health Information DHS discloses to someone involved in your careor the payment for your care, like a family member or friend. For example, you could ask that DHSnot share information about a particular diagnosis or treatment with your spouse. To request arestriction, you must make your request, in writing, to the above-referenced HIPAA Privacy Officer.DHS is not required to agree to your request unless you are requesting DHS restrict the use anddisclosure of your Protected Health Information to a health plan for payment or health care operation


purposes and such information you wish to restrict pertains solely to a health care item or service forwhich you have paid out-of-pocket in full. If DHS agrees, we will comply with your request unless theinformation is needed to provide you with emergency treatment.

Right to Request Confidential Communications. You have the right to request that DHScommunicate with you about medical matters in a certain way or at a certain location. For example,you can ask that DHS only contact you by mail or at work. To request confidential communications,you must make your request, in writing, to the above-referenced HIPAA Privacy Officer. Your requestmust specify how or where you wish to be contacted. DHS will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You mayrequest a copy of this notice at any time. Even if you have agreed to receive this notice electronically,you are still entitled to a paper copy of this notice. To obtain a paper copy of this notice, pleasecontact the above-referenced HIPAA Privacy Officer.

CHANGES TO THIS NOTICE:

DHS reserves the right to change this notice and make the new notice apply to Health Informationalready obtained as well as any information received in the future. DHS will post a copy of the currentnotice at our office. The notice will contain the effective date on the first page, in the top right-handcorner.

COMPLAINTS:If you believe your privacy rights have been violated, you may file a complaint, in writing, bycontacting the above-referenced HIPAA Privacy Officer.You will not be penalized for filing acomplaint.You may also file with the Secretary of the Department of Health and Human Services. For moreinformation on HIPAA privacy requirements, HIPAA electronic transactions and code sets regulationsand the proposed HIPAA security rules, please visit ACOG s web site,http://www.acog.org or call(202) 863-2584.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a writtensignature.

I have read, understand, and acknowledge receipt of the DHS HIPAA Notice of Privacy Practices

MICHAEL H MINYARD


February 28, 2014 at 01:54 P.M.


DECLARATION OF CITIZENSHIP/IMMIGRATION STATUS

Georgia Department of Human Services

Division of Family and Children Services

I understand that the Georgia Division of Family and Children Services (DFCS) may require verification from the UnitedStates Department of Homeland Security (DHS) of my/my children's citizenship or immigration status when seekingbenefits. Information received from DHS may affect my/my children's eligibility.

Please fill out and sign the following statements as it pertains to the status of each person seeking benefits.

CHILDREN SEEKING BENEFITS

I attest to the identity of the child/children listed above and certify under penalty of perjury,that the information writtenand checked above is true.

MICHAEL H MINYARD

February 28, 2014 at 01:54 P.M.

Name U.S.Citizen Lawfully AdmittedImmigrant

Date Naturalized orAdmitted into U.S.

ianAge: 7

US Citizen

matthewAge: 11

US Citizen


Electronic SignatureI have agreed to submit this application for myself and/or my family. By signing this application electronically, I certifyunder penalty of perjury and false swearing that my answers are true and accurate to the best of my knowledge, includinginformation provided about the citizenship or immigration status for each household member applying for benefits. I alsocertify that:

I understand the questions and statements on this application.I have read and understand my Rights & Responsibilities.I understand the penalties for giving false information or breaking the rules.I understand that the agency may contact other persons or organizations to obtain needed proof of my eligibility andlevel of benefits.I understand that I am not required to report reduction or loss of income, that I may be able to get a higher FoodStamps benefit if I do. I understand that as long as I do not report this reduction or loss in income, my Food Stampsbenefit will not increase.I understand that failure to report or verify any listed expenses will be seen as a statement by me that I do not want toreceive a deduction for the unreported or unverified expenses.I understand I can be punished by law if I do not tell the complete truth.I certify that all of the information provided on this application is true and correct to the best of my knowledge.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a writtensignature.

By checking this box and typing my name below, I am electronically signing my application.

MICHAEL H MINYARD

February 28, 2014 at 01:54 P.M.


Food Stamp Rights and ResponsibilitiesPlease read the following information carefully.

YOU HAVE THE RIGHT TOreceive an application on the day you ask for it.have your application accepted when you file it.have an adult apply for your household if you are unable to.a telephone interview.have your EBT card and PIN within 30 days of the date you file your application, if eligible, orhave your EBT card and PIN within 7 days of the date you file your application, if eligible for expedited services.receive fair treatment without regard to age, sex, race, color, handicap, religious creed, national origin, or politicalbeliefs.have a fair hearing if you disagree with any action on your case.examine your case file and the rules of the program.be notified in advance if your benefits are reduced or stopped due to a change that is not reported in writing.

YOUR RESPONSIBILITIES:you must answer all questions completely.you must sign your name to certify, under penalty of perjury, that all answers are true.you must provide proof that you are eligible.Reporting when your households total gross monthly income is more than 130% of the Federal Poverty Level for thehouseholds size within 10 days of the end of the month that the change occurred.do not sell, trade, or give away your food stamp benefits.use food stamp benefits to buy only eligible items.Food Stamp households CAN NOT use their benefits to purchase non-food items such as beer, wine, liquor,cigarettes, tobacco, pet foods, soaps, paper products and household supplies.Food Stamp households also ARE NOT allowed to purchase food on credit with their benefits.

Penalties:Any household member who breaks any of the food stamp rules on purpose can be barred from the FoodStamp Program for one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. She/hemay also be subject to prosecution under other applicable Federal and State laws. She/he may also bebarred from the Food Stamp Program for an additional 18 months if court ordered.Any household member who intentionally breaks the rules may not get Food Stamps for one year for the firstoffense, two years for the second offense, and permanently for the third offense.If a court of law finds you or any household member guilty of using or receiving Food Stamp benefits in atransaction involving the sale of a controlled substance, you or that household member will not be eligiblefor benefits for two years for the first offense, and permanently for the second offense.If a court of law finds you or any household member guilty of having used or received benefits in atransaction involving the sale of firearms, ammunition, or explosives, you or that household member will bepermanently ineligible to participate in the Food Stamp Program upon the first offense of this violation.If a court of law finds you or any household member guilty of having trafficked benefits for an aggregateamount of $500 or more, you or that household member will be permanently ineligible to participate in the


Food Stamp Program upon the first offense of this violation.If you or any household member is found to have given a fraudulent statement or representation with respectto identity (who they are) or place of resident (where they live) in order to receive multiple Food Stampbenefits, you or that household member will be ineligible to participate in the Food Stamp Program for aperiod of 10 years.For more information about Community Outreach Services, please visit our websiteat:http://www.dfcs.dhr.georgia.gov or call 1-877-423-4746

Medicaid Rights and Responsibilities

I agree to assign to the State all rights to medical support and to payment for medical care from any third party(hospital and medical benefits). I agree to cooperate with the State in identifying and providing information to assistthe State in pursuing any third party who may be liable to pay for care and services. I understand that I must reportany payments received for medical care within ten days. (If you are completing this form on behalf of anotherindividual and do not have the power to execute an assignment for that individual, the individual will need to executean assignment of the rights described above as a condition of his/her eligibility for Medicaid).I agree to give the State the right to require an absent parent to provide medical insurance, if available. I understand Imust get medical support from the absent parent if it is available and must cooperate with the Division of ChildSupport Services in obtaining this support. If I do not cooperate, I understand I may lose my Medicaid benefits andonly my children will receive benefits unless good cause is established.

In the Medicaid program you must also: report changes about you and the other people in your Medicaid case within 10 days; please report:

if you or other household members move if you or other household members change jobs, get a new job, quit a job or get laid off. if you or other household members have a change in income or resources if a family member moves in or out of your home if you or another household member inherits or receives money or property from any source if someone in your home dies or gets married any other changes

tell your case manager when your pregnancy ends. Pregnancy ends with the birth of the baby, a miscarriage or anabortion. You must report the end of the pregnancy within 10 days.

In all programs, you have the right to:

request a fair hearing in writing or in person. You have the right to be represented by a household member, legalcounsel, a relative, a friend or other spokesperson. If you are not satisfied with the action we have taken on yourcase, you can request a hearing by contacting the county office where you applied for benefits or by calling 1-877-423-4746.review some of the material and information in your case file. However, you may not be able to see all of theinformation in the case file, such as names of people who have given us information about you or your householdmembers or information about any criminal prosecutions involving you or any of your household members.decide if you want to provide a Social Security Number (SSN), citizenship, or immigration status. Only the peoplewho give information to us about their SSN, citizenship, or immigration status will be eligible to receive benefits. This


information will be used to check the "Income and Eligibility Verification System" (IEVS) and other computer matcheswith other agencies to verify your income and other points of eligibility. We may also give this information to otherFederal and State agencies to review and to law enforcement officials for them to use in catching people who arerunning from the law. If your household has a Food Stamp or SNAP claim, the information on this application,including the SSN, may be given to Federal and State agencies and private claims collection agencies for them touse in collecting the claim. We will not share your information with the United States Citizenship and ImmigrationServices (USCIS); however, if alien status information has been submitted on your application, this information maybe subject to verification through USCIS and may affect your household's eligibility and benefit level. We will notdeny help to people asking for help because other household members do not provide their SSN, citizenship, orimmigration status. The following federal laws and regulations: 7 U.S.C. 2011-2036, 45 C.F.R. 205.52, 42 C.F.R. 435.910, 42 C.F.R. 435.920, authorize DFCS to request your and your household members social securitynumber(s).decide if you want to provide information about your race and ethnicity. We collect data on race, color, and nationalorigin to ensure we are in compliance with Federal civil rights laws. By providing this information, you will assist us inadministering our programs in a non-discriminatory manner. Your household is not required to give us this informationand it will not affect your eligibility or benefit level.

In all programs, you are responsible for:

giving your worker correct information and providing proof of statements needed to receive benefits. When you signthis form, you are giving your worker permission to get information from your employer, bank, neighbor or others sowe can make sure you are receiving the correct amount of benefits.telling the truth at all times. If you or someone who is applying for you provides incorrect information, you may becommitting a crime, and you may go to jail.providing proof that you or anyone in your household applying for benefits is a U.S. citizen or eligible immigrant.Note: Your worker will give you a list of the ways you can prove your citizenship or immigration status.reporting certain changes in your household situation. Each program has different reporting requirements. See theresponsibilities section for each program for things you need to report.

What Other Responsibilities Do I Have in the Food Stamp Program?In the Food Stamp Program, you are also responsible for:

cooperating with state and federal personnel who work for Fraud Prevention or the Office of Investigative Servicesand who are doing special case reviews. If you do not cooperate and we cannot determine that you are still eligiblefor Food Stamps, your case may be denied or closed.cooperating with Quality Control reviewers when they call or come to your home to interview you about theinformation you have given your case manager. If you do not cooperate with them, your case may be denied orclosed.repaying benefits you should not have received.reporting when your household's total gross monthly income is more than 130% of the Federal Poverty Level for yourhousehold's size. You will be given a form 339, Simplified Reporting Requirement Notice, which explains more about


this.

If you are an able-bodied adult without dependents (ABAWD), you must report when your work hours fall below 20 hoursper week or 80 hours per month.

What Are My Rights and Responsibilities for Reporting Household Expenses in the Food StampProgram?

In the Food Stamp Program, certain household expenses such as shelter costs, medical bills, dependant care costs, andchild support paid outside the home may affect the amount of benefits you receive. If you have heating or coolingexpenses, you may be eligible to receive the standard utility allowance. If you have only one utility expense and it is NOTa heating or cooling expense, you may be eligible to receive a deduction for the actual expense incurred. If you want us toconsider these expenses, you are responsible for reporting and verifying them. If you fail to report or verify theseexpenses, we will not use them to determine your benefit amount.

What Are the Penalties in the Food Stamp Program?

In the Food Stamp Program, there are penalties:

If you ... You will lose food benefits ...

hide information or don't tell the truth.use EBT cards that belong to someone else.use food benefits to buy alcohol or tobacco.trade or sell benefits or EBT cards.

for 12 months for the first offense,24 months for the second offense,and permanently for the thirdoffense.

trade or sell food benefits for drugs and were convicted prior to 8/22/96. for 12 months for the first offenseand permanently for the secondoffense.

trade or sell food benefits for drugs and wereconvicted of less than $500 on or after 8/22/96.

for 24 months for the first offenseand permanently for the secondoffense.

trade or sell food benefits for drugs and wereconvicted of $500 or more on or after 8/22/96.

permanently.

trade food benefits for firearms,ammunition or explosives.

permanently.

give false information about where youlive so you can get food stamp benefits inmore than one state.

for 10 years.

commit and are convicted of a felony related topossession, use or distribution of drugs, on orafter 8/22/96.

permanently.

flee to avoid prosecution, custody or confinement for a felony. until you are no longer fleeing.


Child Care Rights and Responsibilities

The information you share with the eligibility authority is confidential. This means that what you tell the eligibilityauthority cannot be shared with anyone other than the Department of Human Services (DHS) without your permissionexcept for officially designated program review agents.You have a right to see your case file unless this is prohibited by Federal or State law or regulationYou have a right not to be discriminated against because of political affiliation, religion, race, color, sex, handicap,national origin or age. Should a problem arise about your application, placement or change in service, DHS willaddress it promptly. If you are still not satisfied, you may call 1-877-423-4746 (this is a free call) or file for anAdministrative Hearing.You have a right to file an appeal if your fee increases or your assistance is stopped and you do not agree with thisdecision. Your case manager will help you file an appeal if you wish to do so.I understand that I may receive child care service as long as funds are available and I remain eligible and havecomplied with all CAPS program requirementsI certify that this application for services has been examined by me and that the information given is true and correctto the best of my knowledge and belief.I agree to provide such information as I can to the eligibility authority for the purpose of determining eligibility forassistance.I agree to provide the eligibility authority with information to verify any statements given in this application and herebygive permission to obtain such verification. I will cooperate fully with State and Federal personnel in a quality controlreview.I understand that I am receiving child care because I am, low income, working, in school or in vocational/technicaltraining and in need of child care. It is my responsibility to report any changes in my circumstances to the eligibilityauthority within 10 calendar days of becoming aware of the change.I understand that child care in support of education and training requires me to be enrolled in an approved program,attend and to maintain passing grades.I agree to pay my child care fees to the provider, if applicable.I understand that if I fail to pay my child care fee my CAPS case will be closed.I understand that my child should attend the child care program regularly. If my child must be absent, I should givethe provider as much advance notice as possible. I also understand that some providers may request signedstatements of absences.I agree to report within 10 calendar days if my child(ren) is (are) no longer enrolled in child care or moves out of myhome, or if the absent parent(s) of the child(ren) returns to the home.I understand some child care providers charge for extra services, such as late pick-ups, transportation, etc. Theprovider's rate may also be more than the amount I am authorized to receive through DHS. DHS does not pay forthese extra services. I understand that I am responsible for any amount due to the provider that is not covered undermy eligibility.I understand that I will have to pay the provider if I receive child care during a period in which I am ineligible or for anychild care that DFCS did not authorize.

violate a condition of your probation or parole. until you are no longer a probationor

parole violator.


I understand that the child care provider is NOT affiliated with or an agent of DHS and that the eligibility authority norDHS in no way warrant the services rendered and the provider acts solely as an independent contractor in itscapacity as a child care provider.I understand that if I have a child care overpayment for services that I may be terminated or denied access to theprogram (s).Under Georgia Law, any person who by false statements, withholding information, impersonation or other fraudulentdevice, obtain or attempts to obtain, or any person who intentionally aids or abets such person in obtaining any publicassistance payments, food stamp allotment or medical assistance to which he is not entitled or greater amount thanthat which he is entitled, shall be punished for a misdemeanor unless the amount obtained exceeds $500 in whichevent he may be punished for a felony. (See Georgia Code OCGA 49-4-45 for the full reference.) I understand themeaning of this paragraph.

PARENT REPORTING RESPONSIBILITY

You are required to notify the Eligibility Agent at least 10 days in advance if you know of a pending change in your need orarrangements for child care services. Failure to notify the program may lead to a termination of your child care case andpossible repayment of all child care funds paid on behalf of the client.

Examples of such changes include, but are not limited to:Change in family size/compositionChange in family incomeParent or child moves out of the homeA child returns or is born into the homeChange of addressChange in school schedule (e.g., classes taken, class hours) New job, job loss, job change or change in work days or hours

Non-Discrimination StatementIn accordance with Federal law and U. S. Department of Agriculture (USDA) and U.S. Department of Health and HumanServices (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age,or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion orpolitical beliefs.

To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office ofAdjudication, 1400 Independence Avenue, S.W., Washington D.C. 20250-9410 or call (866) 632-9992 (voice). Individualswho are hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800)845-6136 (Spanish). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue,S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equalopportunity providers and employers.

Under the Department of Community Health (DCH) policy, Medicaid cannot deny you eligibility or benefits based on yourrace, age, sex, disability, national origin, or political or religious beliefs. To report Medicaid eligibility or provider


discrimination, call the Georgia Department of Community Health's Office of Program Integrity at (404)656-4496 (local);(800) 533-0686 (toll free).

You may also file a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street,N.W., Suite 19-248, Atlanta, GA 30303, or call (404) 657-3735 or fax (404) 463-3978.


food stamps 28 feb 2014

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